Provider Demographics
NPI:1700306669
Name:JARA, CARISSA (CADC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:JARA
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 W M 32
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9282
Mailing Address - Country:US
Mailing Address - Phone:989-732-1791
Mailing Address - Fax:989-732-7052
Practice Address - Street 1:2136 W M 32
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9282
Practice Address - Country:US
Practice Address - Phone:989-732-1791
Practice Address - Fax:989-732-7052
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164641676OtherORGANIZATIONS NPI NUMBER